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Do patients outlive their shoulder prosthesis?
⁎Corresponding author: Tarek Haj Shehadeh. tarekhc5@gmail.com
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Received: ,
Accepted: ,
This article was originally published by Reed Elsevier India Pvt. Ltd. and was migrated to Scientific Scholar after the change of Publisher.
Abstract
Abstract
Total shoulder arthroplasty (TSA) is projected to exponentially increase in the near future. Despite having excellent long-term survivorship, revision surgery remains a key metric in the implant's success. With an increasingly aging population, it is key to understand the relative incidence of death compared to revision surgery to better guide patients counseling and surgical decision-making. In this study, we aim to compare the rates of revision surgery and mortality following TSA in patients aged <65 and ≥ 65.
We queried the TriNetX database for patients undergoing TSA. Patients were grouped into two cohorts depending on age at surgery (<65 and ≥ 65), and were followed up for 10 years after surgery. Incidence of death and revision surgery were compared between the two cohorts. Significance was set for p < 0.05.
135,021 patients were initially included in this study. 106,777 patients formed the cohort aged ≥65 compared to 28,244 patients in the cohort aged <65. The cumulative incidence of mortality was 22.9 % while that of revision was 6.1 % for the ≥65 cohort, while the cumulative incidence of mortality was 7.0 % and revision was 9.4 % for the <65 cohort. The old cohort had significantly lower odds of revision compared to the younger cohort (3.2 % vs 3.5 %, OR = 0.911, p = 0.011), however had significantly higher odds of mortality compared to the young cohort (7.2 % vs 1.9 %, OR = 4.021, p < 0.0001).
Patients younger than 65 years had a higher risk of revision surgery but a lower risk of mortality compared to those older than 65 years. Younger patients appear more likely to require revision during their lifetime, whereas older patients are more likely to outlive their implants. These findings underscore distinct risk profiles across age groups and can guide individualized counseling and surgical planning.
Keywords
Shoulder replacement
Death
Revision surgery
Age
Risk
1 Introduction
The prevalence of total shoulder arthroplasty (TSA) procedures has increased significantly over the past two decades.1 Despite having good long-term survivorship,2,3 the incidence of revision TSA procedures is expected to increase even more than primary TSA.4 Furthermore, older patients comprise most of the individuals undergoing TSA procedures1 and are one of the fastest growing demographics.5
Patients older than 75 years have been shown to have lower revision surgery risk than younger patients.6 Unsurprisingly, data suggests that older patients also have greater 1-year mortality as compared to younger patients.6 Understanding the incidence of mortality as it relates to the likelihood of revision surgery, for patients undergoing TSA, is an important relationship for surgeons to counsel patients.
However, the literature is lacking on data concerning revision and mortality following TSA beyond 5 years. Additionally, with an increasingly aging population, it is key to understand the relative incidence of mortality compared to revision surgery for patients undergoing TSA. Therefore, we aim in this study to compare the rates of revision surgery and mortality following TSA in patients aged <65 and ≥ 65.
2 Methods
We performed a retrospective cohort study utilizing the TriNetX Global Collaborative Network, a comprehensive research platform that aggregates de-identified electronic health records from over 100 healthcare institutions worldwide. This network offers detailed clinical information, including diagnostic codes, procedural data, medications and laboratory values. Since TriNetX extracts data directly from clinical records rather than insurance claims, it ensures greater coding accuracy and consistency. Furthermore, standardized data formatting across institutions allows for robust cross-system comparisons. The patient query was executed on September 10, 2025, and included all individuals who underwent total shoulder arthroplasty (TSA) within the past 20 years. Patients were categorized by age at the time of surgery using a 65-year cutoff and followed longitudinally for up to 10 years postoperatively. Primary outcomes included the incidence of revision surgery and all-cause mortality. Data extraction employed ICD-10, SNOMED CT, and CPT coding systems. As the study used only de-identified records without personal health information, it qualified for exemption from Institutional Review Board oversight. A complete list of the codes used is provided in Supplementary Table 1.
The TriNetX built-in analytic tool was used to compute our analysis. Competing risks analysis was performed to calculate cumulative incidences for each outcome within each cohort. We compared the incidence of death and revision between the two cohorts using the chi-square test, with significance set at α < 0.05.
3 Results
A total of 135,021 patients were included in this study. 106,777 patients formed the cohort aged ≥65 while the cohort aged <65 comprised 28,244 patients. The two cohorts had significant differences in multiple comorbidities, as shown in Table 1. The cumulative incidence of mortality was 22.9 % (95 % CI: 11.4 %–36.8 %) while that of revision was 6.1 % (95 % CI: 4.3 %–8.4 %) for the ≥65 cohort. On the other hand, the cumulative incidence of mortality was 7.0 % (95 % CI: 4.2 %–10.8 %) and revision was 9.4 %, (95 % CI: 6.6 %–12.8 %) for the <65 cohort.
| Characteristic | ≥65 (n = 106,777) | <65 (n = 28,244) | p-value |
| Age at Index (Mean±SD) | 71.3 ± 7.2 | 51.7 ± 8.8 | <0.001 |
| Male | 41.3 % | 55.4 % | <0.001 |
| Female | 56.6 % | 43.3 % | <0.001 |
| Hypertensive diseases | 57.0 % | 31.9 % | <0.001 |
| Disorders of lipoprotein metabolism and other lipidemias | 49.5 % | 24.3 % | <0.001 |
| Type 2 diabetes mellitus | 20.1 % | 11.6 % | <0.001 |
| Osteoporosis without current pathological fracture | 12.1 % | 3.3 % | <0.001 |
| Heart failure | 8.2 % | 3.3 % | <0.001 |
| Chronic kidney disease, stage 3 (moderate) | 7.5 % | 2.1 % | <0.001 |
| Chronic kidney disease, stage 2 (mild) | 2.1 % | 1.0 % | <0.001 |
| Osteoporosis with current pathological fracture | 1.6 % | 0.6 % | <0.001 |
| End stage renal disease | 0.6 % | 0.6 % | 0.637 |
| Chronic kidney disease, stage 4 (severe) | 1.1 % | 0.5 % | <0.001 |
| Chronic kidney disease, stage 1 | 0.4 % | 0.2 % | <0.001 |
| Chronic kidney disease, stage 5 | 0.3 % | 0.2 % | 0.672 |
| Osteonecrosis due to drugs, shoulder | 0.1 % | 0.3 % | <0.001 |
| Insulin use | 14.7 % | 10.0 % | <0.001 |
| Primary osteoarthritis, shoulder | 57.4 % | 42.0 % | <0.001 |
| Rotator cuff tear or rupture, not specified as traumatic | 35.4 % | 29.3 % | <0.001 |
| Fracture of upper end of humerus | 11.3 % | 7.0 % | <0.001 |
| Adhesive capsulitis of shoulder | 3.9 % | 4.5 % | <0.001 |
| Post-traumatic osteoarthritis, shoulder | 1.8 % | 2.5 % | <0.001 |
| Secondary osteoarthritis, shoulder | 1.6 % | 1.6 % | 0.642 |
| Idiopathic aseptic necrosis of humerus | 0.7 % | 1.6 % | <0.001 |
| Arthroscopy, shoulder, surgical | 4.5 % | 7.2 % | <0.001 |
| BMI (mean±SD) | 30.3 ± 6.5 | 31.8 ± 7.3 | <0.001 |
| Hemoglobin A1c (mean±SD) | 6.0 ± 1.1 | 5.9 ± 1.2 | <0.001 |
The Aalen-Johansen cumulative incidence curves for both cohorts are shown in Fig. 1.
Comparing both cohorts, the old cohort had significantly lower odds of revision compared to the younger cohort (3.2 % vs 3.5 %, OR = 0.911 (0.848–0.979), p = 0.011), but had significantly higher odds of mortality compared to the young cohort (7.2 % vs 1.9 %, OR = 4.021 (3.680, 4.393), p < 0.0001).
4 Discussion
The most notable findings of the present study include: 1) patients less than 65 years were more likely to have revision TSA during their lifetime, and 2) mortality was more common than revision TSA in patients aged more than 65 years during the period of 10 years after surgery. 3) older patients are at higher odds of facing mortality and lower odds of undergoing revision compared to the young cohort.
Multiple studies reported on the indications for revision TSA. Vancolen et al. reported that cuff failure (40 %), failed prior arthroplasty (35 %), OA and glenoid component issues (both 4 %) were the most common documented indications for revision RSA in patients younger than 65 in their systematic review of 6 studies.7 Another systematic review by Gulzar et al. of 13 studies reported that the most common indications for anatomic TSA revision were glenoid arthrosis and glenoid component failure.8 The differing indications across arthroplasty types are noteworthy, as they often align with variations in patient age, comorbidity profiles, and underlying disease etiology. These differences underscore the importance of carefully considering not only age and medical comorbidities but also the type of indication driving the need for surgery when evaluating candidates for arthroplasty.
In our cohort, the cumulative incidence of revision surgery over 10 years remained relatively low, aligning with large database studies that report revision rates between 2 % and 10 % depending on age, implant type, and indication for surgery.9–13 In a large Nordic registry study of 1904 patients undergoing primary reverse shoulder arthroplasty, the authors reported a revision rate of 5 %.11 In a retrospective study across two tertiary centers and average follow-up of 8.7 years, Gauci et al. reported a revision rate of 6.7 % for TSAs and 3.9 % for RSAs, most commonly due to glenoid failure and instability.10 Interestingly, in a retrospective study of 110 patients older than 83 years who underwent RSA, the reported revision rate was 2.4 % and 6.5 % following elective and fracture cases, respectively, for an average follow up of 30 months. Zhou et al. reported increasing lifetime revision risks with decreasing age, starting at around 35.9 % for TSA and 31 % to RSA in patients aged between 46 and 50 years.3
Currently, the literature on long term mortality rates following TSA is lacking. Khan et al., of the Avant-garde Health and Codman Shoulder Society Value-Based Care Group, in a large study of 108,667 shoulder arthroplasty cases with an average age of 74.3 years, reported a mortality rate of 16.6 % at five years postoperatively.14 Amundsen et al. queried the Danish Shoulder Arthroplasty Registry, including 5853 cases with an average age of 69.3 years and reported a mortality rate of 0.7 % at 30 days, 1.5 % at 90 days, and 3.8 % within 1 year.14 In a similar study on 640 SA cases, the mortality rate was estimated at 0.16 % at 3 months and 2 % at 1 year following TSA in a patient population with an average age of 72 years at time of surgery.15 Interestingly, in a study of 242 RSA for patients older than 80 years, 19 % died at the final follow-up, while the revision rate was estimated at 1.1 % at 2 years and 1.7 % at 5 years.16 In our study, over 10 years, we found that the older cohort (≥65 years) had higher mortality risk compared to the younger cohort. Importantly, the older cohort had higher cumulative incidence of death than revision. This data suggests that for many patients, especially for older patients, TSA is a terminal intervention, meaning it is likely to remain in situ for the remainder of the patient's life without requiring revision.
The relationship between revision surgery and mortality risk has important implications for clinical decision-making, implant selection, and patient counseling. Interestingly, several studies have shown that younger patients are at significantly higher risk for revision due to various reasons.3,13,17 Our findings align with this, as we showed that the older cohort had lower odds of revision compared to the younger cohort.
Limitations of this study include the retrospective design, and reliance on a database which may underestimate the true incidence of revision due to loss to follow-up or incomplete capture. Furthermore, we did not evaluate cause-specific mortality, time to revision, revision rate by implant type or surgical indication, which may yield more granular insights in future studies.
In conclusion, the incidence of revision surgery following TSA in older individuals is relatively low and is often outpaced by patient mortality. Younger individuals remain at higher risk of revision surgery during their lifetime as compared to older cohorts. This underscores the importance of individualized, patient-centered surgical planning and shared decision-making that considers life expectancy, comorbidity burden, and functional goals.
Guardian/patient's consent
We only used de-identified data provided by TrinetX. As such, no consent or IRB approval was needed.
Ethical statement
We only used de-identified data as provided by the TriNetX research database.
Author contributions
Conceptualization: THS, NL; Data curation: THS; Formal analysis: THS; Investigation: THS; Methodology: THS; Project administration: THS; Resources: THS; Software: THS; Supervision: THS; Validation: THS; Visualization: THS; Roles/Writing - original draft: THS, AE, NL; and Writing - review & editing: THS, AE, GU,NL.
Funding statement
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
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